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Sudden cardiac death among high school athletes is a very infrequent though tragic occurrence. Despite widespread preparticipation screening for known causes of this event, the frequency has not changed. The ECG is an acknowledged sensitive screening tool for the common causes of sudden cardiac death in young athletes. The specificity of the ECG in this setting is believed to be relatively low in young athletes for which reason, in part, it is not used. We added an ECG to the usual preparticipation screening. An echocardiogram was performed when screening was abnormal. Outcome measures of serious or potentially serious cardiovascular abnormalities were defined by the 16th Bethesda Conference. These abnormalities either preclude sports participation or require further testing before approval for participation in sports can be considered. Over 3 yr, 5,615 male and female high school athletes were screened prospectively from 30 different high schools in northern Nevada. Outcome measures were detected in 22 athletes or one per 255. Cardiac history led to detection of outcome measures in 0 athletes, auscultation/inspection in 1/6,000 athletes, blood pressure measurement in 1/1,000 athletes, and the ECG in 1/350 athletes. Specificity was 97.8% for an abbreviated cardiac history and auscultation/inspection and 97.7% for ECG. Overall, the ECG was a much more effective screening tool than cardiac history and auscultation/inspection in detecting cardiovascular abnormalities requiring further tests before approval for participation in sports could be given. ECG and cardiovascular history/auscultation/inspection had similar specificity ECG was efficiently performed on large groups of high school athletes.